GW1--06673_Well Construction - GW1_20231017

vv. .a.a.,%Ain a1nut;iluiN RECORD(GW-11 For Internal Use Only:
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1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A 25°ft. .25i ft. a 6,pt n
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) _
Aqua Drill, Inc. FROM TO DIAMETER
I/DIAMETER THICKNESS MATERIALAT
Company Name 0 ft. ICJ , )t. 1' 17Y in. ISDJZ2 1 I I `V e C
)1 y if 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ireQ305 0 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance.etc.) ft. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supplyl Well: 17.SCREEN
A cultura FROM TO DIAMETER- SLOT SIZE THICKNESS . MATERIAL
Stu OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) + ' idcntial Water Supply(single)
ft. fL in.
Industrial/Commercial MI Residential Water Supply(shared)
18.GROUT •
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. . .C) it• i > €/t9i 01:1
Monitoring jRccovery ft. ft. tr?
Injection Well:
Aquifer Recharge ft. ft.
qu g Groundwater Remediation
Aquifer Storage and Recovery 0Selini Barrier 19.SAND/GRAVEL PACK(if applicable) ,
ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DIStormwater Drainage ft. ft.
i
Experimental Technology .oSubsidence Control ft. ft.
Geothermal(Closed Loop) tiriTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type.grain stag eta)
4.Date Well(s)Completed-1 l�2.3 Well ID# ft. 6 ft. 5 ii,ad l oG p
So.Well Location: -
�t��o I- t1s6 it, s-ft. 13i� G;�=1 ;,1
[t. f(.
Facility/Owner Name Facility ID#(if applicable) ft, ft.
s'cf . m clefn, f 12. urvilt l tiuZF.I rf I Ni•C ft. ft.
Physical Address,City,an Zip ft. ft.
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C t i.
•V t Cik 21.REMARKS
aun ty Parcel Identification No.(PIN) ' U L 1 % ��23
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Irlf:-;:.r,..- 3-:1 P--,.;,.,,,:,_: ,,r.;
(if well field,one lat/long is sufficient) 22.Certifica'on: v + ;`
N W ` !
p ry Si lure ofCcrific Well Contract I. Date
6.Is(are)the well(sPermanent or Tem ora
By signing this form,I hereby car*thai the walls)nos(were)constntcted in accordance
7.Is this a repair to an existing well: DYes or IONo with ISA NCAC 02C.0100 or ISA NCAC'02C.0200 Well Construction Standards and that a
If this Ls a repair,fill nut known well construction infonna:ion and explain the nature of the copy alibis record has been provided to the well owner.
repair under#21 remarks section or on the hack of this farm. -
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r,2(o (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdperent(example-47 00'and 2®100)
construction to the following:
10.Static water level below top of casing: f 0 (ft.) Division of Water Resources,Information Processing Unit,
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If water level is above casing,use'+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ( G+ (in.) 24b.For Infection Wells: In addition to sendingthe form
/� to the address in 24a
12.Well construction method: .4ilz f�;`� above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636 -
13a.Yield(gpm) S 0 Method of test: r 4 24c.For Water Simply&Infection'Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:i' Amount:q 0 completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016